370

(Presentation of a case history of interest to anesthesiologists is a

feature of each issue of Anesthesia and Analgesia. Readers are invited to
send in case reports for discussion. This feature is conducted b y Associate
Editor Morris J . Nicholson, M.D., 605 Commonwealth Avenue, Boston 15,
Massachusetts.)

ASEPTIC
MENINGITIS
SPINAL
ANESTHESIA
Case History No. 37
was administered
S
to 3 patients in active labor for vaginal delivery during a 24-hour period.
PINAL ANESTHESIA

The first patient was a 21-year-old gravida I1 para 1, t h e second was a 26-yearold gravida I1 para 1, and the third was
a 40-year-old gravida V p a r a 4. All
three had been well during their pregnancy and continued so until time of
delivery. A t approximately 3 to 4 hours
after delivery each patient complained
of the onset of a severe, constant, pounding headache in t h e frontal and occipital
regions, which was aggravated by motion. The headache increased in severity
and was followed by pains in the low
back region and legs. Over the next
several hours nuchal rigidity was noted.
The leg and back pain subsided at the
end of 12 hours, and t h e nuchal rigidity
disappeared in 60 to 65 hours, but the
headache persisted for 48 hours.

During the first 12 hours after delivery, the body temperature rose to a
maximum of 102" F. and by the end of
24 hours it was back to normal where
it remained. Four to 8 hours after anesthesia t h e w h i t e blood cell count
ranged from 19,000 to 25,000 with a
differential of 65 to 70 per cent polymorphonuclear cells and 10 to 15 per
cent band forms. This leukocytosis continued for an average of 18 hours. Nausea, retching, a n d vomiting occurred
during the first 12 hours after delivery.
These patients did not complain of photophobia, of sensory or motor changes,
or of difficulty with bowel and bladder
function at any time during these episodes. On examination at the end of 48
hours t h e sensory and motor systems
in t h e lower extremities and perineum
were found to be intact.

371

ANESTHESIAand ANALGESIA. . . Current Researches Vot. 43, NO. 4, JULY-AUGUST,1964

Treatment of all three of these patients during this acute phase was symptomatic. DemeroP w a s administered
for the control of pain, Thorazine@ for
the nausea, and intravenous fluids to
maintain fluid balance. Sigmagen@*, 2
tablets 4 times a day, was given for 3
days. The third patient received 100
mg. of Soh-Cortef@intravenously in 1
liter of 5 per cent glucose in water during the first 5 hours. All 3 patients were
kept in bed for 48 hours, during the first
24 hours of which without elevation of
the head; following this they were allowed up as desired. The patients assumed t h a t they had had a routine postlumbar puncture headache. Their attending physicians were told t h a t the
tentative diagnosis was aseptic meningitis, and the necessity was pointed out
for a careful follow-up a t 1, 2, 6, and 12
months in order to check against the
possibility of neurologic sequelae.
The spinal anesthetic technic in each
of these patients was identical. The skin
over t h e lumbar region was prepared
with 2 applications of tincture of Zephirans which was allowed to exert its
effect while the spinal anesthetic agents
were being prepared. The anesthesiologist used pHisoHex@ for his hands and
wore sterile gloves. Procaine, 1 per cent
solution, was used t o produce t h e skin
wheal and a 24-gauge spinal puncture
needle, without t h e use of a n introducer,
was employed for the spinal tap.
All 3 patients were placed in a left
lateral decubitus position so t h a t they
were in a 10-degree reversed Trendelenburg position. The spinal puncture was
made at the interspace between the third
and fourth lumbar vertebrae, and a left
lateral approach was used. The lumbar
punctures were atraumatic, and a mixture of 40 mg. of 5 per cent Xylocaine@
and 60 mg. of 7.5 per cent dextrose was
diluted t o 1.2 ml. with spinal fluid before
injection into the subarachnoid space.
The clinical course of the patients was
uneventful in the delivery room. Outlet
forceps were used routinely. Each patient received 1500 ml. of 5 per cent
dextrose in w a t e r intravenously, the
first liter of which contained 1 ampule
"Sigmagen tablets contain 0.75 mg. prednisone,
325 mg. acetylsalicylic acid, 20 mg. ascorbic
acid, and 75 mg. aluminum hydroxide; Schering Corporation, Bloomfield, New Jersey.

of Syntocinon@*.The blood pressure and

pulse rates were normal during and immediately a f t e r delivery in e a c h instance.
These 3 consecutive episodes following spinal anesthesia led to a careful
retrospective inquiry into the preparation of the spinal sets. All the trays
were prepared on the same day by the
same person who had performed this
particular function for 4 years, during
which time no previous difficulty of this
nature had been noted. The needles and
syringes had been rinsed with ether and
70 per cent isopropyl alcohol and then
the entire tray, drugs included, had been
autoclaved. The autoclave record was
checked and found t o indicate proper
function. In this hospital, all needles
and syringes in these sets are used solely for spinal trays and are replaced by
new equipment when necessary. The distilled water and alcohol solutions used
t o rinse t h e sets were checked and found
to be satisfactory. The remainder of t h e
ether had been discarded and could not
be checked. The ampules of Xylocaine
were part of a lot that had been in use
for about a week, and no trouble had
developed previously or after these episodes when t h e other ampules of this
lot had been used.
As a result of these investigations,
the anesthesiologist in t h i s h o s p i t a l
thought t h a t at some point in the preparation of the tray there must have been
a deviation from the routine technic.
The occurrence of these episodes in 3
consecutive cases following t h e use of
trays prepared on the same day by t h e
same person makes any other conclusion
impossible. The actual deviation in technic in t h e preparation of these trays is
still not known.
Careful neurologic and obstetric follow-up study of these patients 1, 2, 6,
and 12 months later has failed to show
any evidence of a neurologic defect. It
was concluded, therefore, t h a t these 3
occurrences were instances of aseptic
meningitis associated with t h e use of
s p i n a l anesthesia. On this obstetric
service this type of anesthesia is used
by choice and such a complication had
never been encountered before nor has
it appeared during t h e subsequent 13month interval.
"1 cc. contains 10 U.S.P. units of oxytocin;
Sandoz Pharmaceuticals, Hanover, New J e r sey.

Case History

. . .

372

Case No. 37

COMMENT
Morris J. Nicholson, M.D.

These case histories concern a known and occasionally reported complication of spinal anesthesia-aseptic meningitis. Such factual reports should
serve as frightening reminders to the anesthesiologist of the importance
of everything he does in his daily practice. Retrospective investigations
designed to pinpoint the cause for such periodic complications generally
serve only to remind the anesthesiologist of his dependence on the manufacturing pharmaceutical company, suppliers of intravenous fluids and intravenous sets, operating room personnel (doctors, nurses, and technicians),
the technics used in the central supply area for the cleaning, packaging,
sterilizing, storage, and distribution of hospital supplies, and so forth.
Reappraisal of all these essentials must ever remain dynamic and constantly under our critical re-evaluation and improvement if we are to
eliminate completely such complications.
Past experience has demonstrated the value of using commercially available, sterility controlled, disposable equipment for the collection and administration of blood, blood fractions, and intravenous fluids.
Prepackaged sterile disposable spinal sets have been commercially available and in clinical use for several years, and it would seem t h at this
might be a way of eliminating aseptic meningitis. I would like t o hear from
anyone whose use of these commercially available spinal sets has been
associated with the development of aseptic meningitiq.
We are fortunate in being able to bring to your attention an article
entitled An Epidemic of Chemical Meningitis, by Drs. Winfrey W.
Goldman and Jay P. Sanford. These authors provide a fine discussion of
the problem of aseptic meningitis associated with spinal anesthesia in
obstetrics and they include 3 very thoroughly studied cases from their own
practice.

AN EPIDEMIC OF CHEMICAL MENINGITIS*

WINFREY W. GOLDMAN, JR., M.D.?
JAY P. SANFORD, M.D.t

Meningitis following the administraDuring an eleven-month period we obtion of a spinal anesthetic may be the served five patients$ in whom a n acute
consequence of a number of factors: purulent aseptic meningitis developed
trauma from t h e procedure itself, ag- shortly following spinal anesthesia which
gravation of an underlying disease of seemed to be a result of t h e chance use
the central nervous system, contamina- of syringes contaminated with t r a c e
tion with viable bacteria, inflammatory a m o u n t s of a p h e n o l i c disinfectant.
response to the anesthetic agent or med- Based on these observations and review
ication, or a n inflammatory response to of previous clinical a n d experimental
a foreign irritant (chemical) which has studies, the pathogenesis, clinical feacontaminated the equipment used dur- tures and means of prevention of this
syndrome are summarized.
ing the anesthetic procedure.
*Abridged from the American Journal of Medicine (July) 1960, pp. 94-101.
+Department of Internal Medicine, The University of Texas Southwestern Medical School,
Dallas, Texas.

CASE REPORTS

The following women were admitted

$Only three of the five cases reported in original paper are included in this abridgement.

ANESTHESIA
and ANALGESIA.
. Current Researches VOL.43, No. 4, JULY-AUGUST,
1964

373

to Parkland Memorial Hospital for delivery of uncomplicated full-term pregnancies. None demonstrated signs or
symptoms of acute or chronic disease
prior to delivery. These cases are sporadic, considering the number of spinal
anesthetics administered d u r i n g this
period by the Department of Obstetrics
and Gynecology.
Case I (Fig. 2 ) . A twenty year old
gravida 4, para 1 housewife with two
previous spontaneous abortions was hospitalized in March 1958 in active labor.
Saddle block anesthesia, using 4 mg.
tetracaine hydrochloride, w a s accomplished with some difficulty. Delivery
was uncomplicated. Eight hours after
administration of the anesthetic her oral
temperature was 101.4' F. rising t o
101.8' F. Six hours later severe headache, backache and nuchal rigidity were
noted. There were no residual effects
of the anesthetic and no neurological
changes were detected. On lumbar punc-

I
2

w:

24

HOUR

PERIODS

Opening pressure
180 mm CSF
7,200 cells/mm3
0070PMN
Protein 48mgr7.

Sugar 58mg.%
Blood sugar 75rngs%

' U

W 0 C count:
t8,aoo/mm3
7 7 Yo PMN
2 YU Bands
20% Lymphocytes
1% Eosinophils

&
C

Opening pressure
150 mrn CSF
15 cetts/mrn3
AlL lymphocytes

Protein 35 mg5%
Sugar 65mgsO/o
Blood sugar 86mgs%

for organisms

*~rgsta/crirepenici//ti, 20 to JO m. U . cr.~t./y
Ch/oromphenrko/ 2 gms. dU/?Y
P o f ~ m ~ x fBi , f.5gnrs. d U 4 Y

FIGURE
1

ANT/B/OT/CS *
CSF:

Opening pressure
jOOmmCSF
5,000 calls/mm'
S O P PMN
Protein 200mgr7%
3ugar Sbmg.70
Smear negative

ture, the CSF pressure was increased

and the CSF contained 5,000 cells/cu.
mm. with 90 per cent polymorphonuclear cells, protein 200 mg. per cent and
sugar 68 mg. per cent. No organisms
were seen on stained smears of the CSF
sediment. Blood and CSF cultures were
negative. Results of serologic tests for
syphilis were negative. Again, bacterial
contamination was considered and the
patient was treated with penicillin, chloramphenicol and polymyxin B. She had
clinically recovered and was afebrile in
less than twenty-four hours after onset
of the illness. The patient was examined five months after the meningitis
and was found to have no neurological
abnormalities.
Case I1 (Fig. 2). A fourteen year old
girl was admitted in July 1958 in active
labor for delivery of her first child. Saddle block anesthesia was performed using 4 mg. tetracaine hydrochloride ; a n
uneventful delivery followed. Approxi-

WBC count:
8,050/mm~
54% PMN
0 % Bands
37% Lymphocytes
iyo Eosinciphils

Case History

. . .

374

Case No. 37

t:B.
f4 N.

103'

P
E

102'

99'

I.

CSF:
Opening pressure
150 mm CSF
2,600 c c t i s / m d
95 70 PMN
Rotein 46Snqs70
Smear newtive
qor orgaiicrnc
Sugar not obtained

W B C count:
i i ,500/mm3
8 6 % PMN
4% Bands
iO% Lymphocytes

WBC 'count:
9, 200/mm5
57% PMN
2070 Bands
23% Lymphocytes

-PMH

I
f72f05

SSF:
ib cells/mm3
78% Lymphocytes
Protein 27rngs70
Sugar not obtained

FIGURE
2

mately four hours after t h e administration of the anesthetic she had a chill.
Within a n hour her oral temperature
was 103" F. and she complained of severe headache and backache; she was
found to have nuchal rigidity. Motor and
sensory residuals of the anesthetic were
minimal. The CSF contained 2,600 cells/
cu. mm. with 95 per cent polymorphonuclear cells, and protein 465 mg. per
cent. Organisms were not demonstrated
on stained CSF smears and blood, and
CSF cultures were negative. Results of
serologic tests for syphilis were negative. Shortly after onset of the meningitis the peripheral w h i t e blood cell
count was 11,5OO/cu. mm. with a shift
to the left. The patient was treated with
penicillin and chloramphenicol. Within
forty-eight hours she was afebrile and
asymptomatic, with no neurological abnormalities.
Case I11 (Fig. 3 ) . A seventeen year
old primigravida housewife was admitted in active labor in August 1958. Sad-

dle block anesthesia was performed using 4 mg. tetracaine hydrochloride; an

uneventful delivery followed. Thirteen
and a half hours after administration of
the anesthetic her oral temperature was
101" F. and she complained of headache
and backache. There was nuchal rigidity but no other neurological findings.
The CSF contained 2,730 cells/cu. mm.,
94 per cent of which were reported as
"lymphocytes" (this was not checked by
the medical staff). The CSF protein was
172 mg. per cent and t h e sugar was 63
mg. per cent. No organisms were seen
on stained smears of the CSF. Blood
and CSF cultures were sterile. Results of
serologic tests for syphilis were negative. The peripheral white blood cell
count shortly after onset of meningitis
was 16,05O/cu. mm. with a shift to the
left. The patient was treated with penicillin and tetracycline. T w e n t y - f o u r
hours after onset of illness she was
asymptomatic and afebrile. There were
no neurological changes a t the time of
discharge.

375

...

ANESTHESIA
and ANALGESIA Current Researches VOL. 43, NO. 4, JULY-AUGUST,
1964

, 4 0 1

P 102'
E f131

1
Opening pressure
145 mm CSF
2,730 cells/mm3
04%Lymphocytes
Protein 172 mgsT
Sugar 63 m-70
Smear negative
for organism

ANT/8/OT/CS
W B C count:
i6,050/mrn3
78 70PMN
570 Bands
17% Lymphocytes

I
CSF:
6 Lymphocytes
i PMN

FIGURE
3

COMMENTS
intensive antibacterial therapy directed
The similarities in t h e clinical course against these organisms was initiated in
of these patients were striking. Within each instance. The failure to culture orfourteen hours following spinal anesthe- ganisms from either t h e cerebrospinal
sia (saddle block) utilizing tetracaine fluid or blood suggested the likelihood
hydrochloride an acute meningitis de- of a non-bacterial form of postspinal anveloped. The finding of purulent spinal esthetic meningitis. Another considerafluid with a predominance of polymor- tion was t h a t the trauma of t h e procephonuclear leukocytes, t h e presence of dure had caused bleeding into t h e intrafever and of peripheral leukocytosis with thecal space. The cerebrospinal fluid was
a shift to the left strongly suggested neither bloody nor xanthochromic, and
bacterial meningitis. The possibility of the magnitude of the pleocytosis without
bacterial contamination as a result of frank blood in the cerebrospinal fluid
inadequately sterilized anesthetic agent militated against this view. Aggravaor equipment was considered quite like- tion of an underlying disease of the cenly. Pseudomonas species or coliform or- tral nervous system by spinal anesthesia
ganisms are among the most likely etio- has been reported, especially in patients
logic agents in meningitis following pro- with pernicious anemia, multiple sclerocedures on the central nervous system, sis, tabes dorsalis, general paresis, and
including spinal anesthesia.l However, metastatic and primary neoplasms of
in no instance were organisms demon- the central nervous system.2. l o None
strated on stained smears of t h e cere- of our patients exhibited the clinical feabrospinal fluid sediment and t h e spinal tures of these illnesses and follow-up
fluid sugar concentrations were normal. examinations have failed to detect such
Despite this discrepancy and because of diseases.
our early failure t o appreciate t h e posThus, a n inflammatory response to a
sibility of purulent sterile meningitis, foreign irritant or "chemical meningi-

Case History

. .

Case No. 37

tis was suggested. The occurrence of

untoward reactions to the intrathecal
injection of foreign substances is well
documented.

376

man12 studied eleven s u c h cases and

found t h a t the syringes used for administering t h e a n e s t h e t i c agents were
cleansed in a mild deterpent solution
with only casual rinsing-in t ap water
Early in the use of spinal anesthesia, b e f o r e autoclaving. He demonstrated
aseptic meningeal reactions manifested t h at injection of a similar mild deterprincipally by a cerebrospinal fluid pleo- gent solution into an animal produced
cytosis frequently were reported. Mer- paralysis of the hind legs. Paddison
ritt and Fremont-Smith3 reviewed sev- and Alpers13 also reported a fatal case
eral reports published between 1928 and of adhesive arachnoiditis, nerve root and
1934 in which over one hundred and spinal cord degeneration which they atfifty patients were studied following spi- tributed to detergent remaining in t h e
nal anesthesia; slight to marked cere- spinal anesthesia equipment following
brospinal fluid pleocytosis was found washing. Additional experimental supwithin twelve to twenty-four hours in port came from the observations of Denfrom 65 per cent t o approximately 100 son and co-workers.14~l5 Using syringes
per cent of patients. A predominance of which had been soaked in various deterpolymorphonuclear c e l l s w a s demon- gent solutions, then autoclaved without
strated in some patients, in others the washing, they injected spinal anesthetic
response was lymphocytic. In roughly solutions into the subarachnoid spaces
one-third, there was elevation of the ce- of monkeys; most showed varying derebrospinal fluid protein. However, in grees of arachnoiditis and nerve tissue
1936 Orkin4 summarized t h e reports of damage when sacrificed.
approximately 46,000 administrations of
The second syndrome encountered folspinal anesthetics and reported a n incidence of aseptic meningitis of only lowing spinal anesthesia is an a c u t e
0.26 per cent. Subsequent and more re- meningitis which is apparently benign.
cent studies have not demonstrated a Livingstone and co-workers16 reported
significant incidence of inflammatory two cases and reviewed t h e earlier cas2
response a f t e r s p i n a l anesthesia.5- l 7 reports. In their first case headache,
Kamsler5 reported no cells in the cere- stiff neck, nausea, vomiting and photobrospinal fluid in nine of twelve patients phobia developed within fourteen hours
given a single injection of an anesthetic following spinal anesthesia. There was
agent; 5 cells/cu. mm. was the highest marked lymphocytosis and elevation of
the protein content of t h e cerebrospinal
number found in the other three.5
fluid. On t h e fourth day the patient was
Yet there can be little question t h a t asymptomatic. Their second case was
severe neurological complications still similar. Cultures of t h e cerebrospinal
may occur following spinal anesthesia.0
fluid including guinea pig and mouse inTwo general syndromes have been en- oculations, were sterile in both cases,
countered following s p i n a l anesthesia The authors cal l ed this complication
using procaine or one of its derivatives. chemical meningitis but suggested no
One is a destructive neurological process specific chemical agent. Rendell17 enwhich either may begin promptly, the countered seven similar cases, in six
patient failing to recover fully from t h e of which stiff neck, headache, vomiting
effects of the anesthetic agent or may and lethargy developed within twentybegin after weeks or months. Such com- four hours following t h e administration
plications are usually progressive and of spinal anesthesia, with recovery in
are not associated with fever or overt two to three days. A polymorphonuclinical meningitis. The lesions consist clear leukocyte response in t h e cerebroof progressive demyelinization of the spinal fluid was observed in all seven
spinal roots beginning with the cauda patients. On the premise t h a t inadeequina, chronic adhesive arachnoiditis, quately washed syringes contaminated
hyperplastic pia with marginal demye- by disinfectants were a prime cause of
linization of the cord, or, in some cases, postspinal anesthesia aseptic meningiprogression of the process to a meningo- tis, she obtained syringes which had
encephalitis and sometimes t o internal been stored in a phenolic disinfectant
hydrocephalus. A fatal outcome is not solution, washed them with exaggeruncommon and residual motor and sen- ated care, and injected a spinal anessory deficits are frequent.2*11-13 Winkle- thetic in two patients. In one patient

377

ANESTHESIA
and ANALGESIA.. Curvent Researches VOL.43, NO. 4, JULY-AUGUST,
1964

headache and low grade fever developed

with no other symptoms or signs ; however, the cerebrospinal fluid showed a
large number of polys. Symptoms and
fever were not recorded in the other patient but the cerebrospinal fluid contained over 2,000 polys and the protein was elevated.
Hurstl* has r e p o r t e d experimental
studies in which monkeys were injected
intrathecally with different concentrations of various chemicals including cationic q u a r t e r n a r y a m m o n i u m compounds, anionic detergents, non-ionic detergents and various disinfectants including phenol. He produced pathological changes similar to those described
by others following the use of detergents. However, he reported t h a t such
changes occurred only when rather high
concentrations of the chemicals were injected. Despite the failure to produce a n
experimental acute meningitis in monkeys with trace amounts of phelonic disinfectants, t h e introduction of t r a c e
quantities of such agents into the subarachnoid space of human subjects seems
to produce a n a c u t e benign purulent
meningitis which is not followed by progressive neurological changes.
Because of t h e striking similarity between the patients we observed and t h e
findings of Rendell, t h e technics in the
care of spinal anesthetic equipment and
anesthetic agents which were used in
our patients were reviewed. Four of the
patients were given 4 mg. tetracaine
hydrochloride in 6 per cent dextrose solution distributed in 2 ml. ampoules.
The ampoules were kept in their original
cartons prior to being placed on the anesthetic trays which were then wrapped
and autoclaved. At n o t i m e w e r e t h e
ampoules placed in disinfectant solutions. However, until shortly after t h e
appearance o f the first case, the syring e s u s e d f o r saddle blocks w e r e
cleansed according t o technic utilized
f o r routine syringes in the hospital.
T h i s consists o f soaking syringes in a
phenolic disinfectant solution (2.5 per
cent A m p h y l B ) followed b y washing and
rinsing. I n the Department o f Anesthesia syringes f o r spinal anesthesia were
kept entirely separate f r o m other syringes and cleansed only in distilled water, alcohol and ether. This procedure
was instituted b y t h e Department of
Obstetrics and Gynecology following the

first episode o f chemical meningitis.

H o w e v e r , m a n y of t h e t r a y s prepared
b y the older method w e r e k e p t and periodically reautoclaved w i t h o u t opening
the t r a y s and rewashing. A l s o , it was
possible that sporadic breaks in the
procedure allowed a disinfectant-soaked
routine hospital syringe to be included
in t h e trays. I n several o f these patients
t h e spinal anesthesia w a s technically
d i f i c u l t and it w a s quite certain that
additional routine syringes w e r e utilized. A f t e r reviewing the clinical amd
experimental observations relating t o
meningeal irritation following spinal anesthesia, w e believe that the five patients
herein described clearly represent chemical meningitis secondary t o t h e intrathecal injection o f phenolic disinfectant
w h i c h contaminated t h e syringes used
in t h e procedures.

If the problem of chemically contaminated syringes as used in various procedures is considered, t h e implications
extend beyond spinal anesthesia. The
seemingly unpredictable and capricious
reactions t o many intrathecal medications, including antibiotics, d y e s a n d
other agents may be explained in part
by t h e use of chemically contaminated
equipment. It is essential t h a t equipment which is t o be used for the administration of i n t r a t h e c a l materials
must be handled according to procedures
which are designed to eliminate completely exposure to chemical cleansing
or disinfecting agents.
SUMMARY

1. Five patients* in w h o m aseptic

meningitis developed following spinal anesthesia are described. Initially, each
patient appeared to have an acute bacterial meningitis. In the majority, the
onset of cl i n i cal meningitis occurred
within fourteen hours following the administration of the s p i n a l anesthetic.
Recovery was prompt and no neurologic
changes were encountered.
2. Review of the clinical and experimental observations relating to meningeal irritation following spinal anesthesia supports t h e impression t h a t these
patients had a chemical meningitis secondary t o t h e intrathecal injection of
phenolic disinfectants remaining on syringes following a cleansing procedure
employing a phenolic disinfectant.
Three, in this reprint.

Case History

. . .

378

Case No. 37

3. The necessity for more stringent

procedures in preparing syringes which
are to be used for the administration of
intrathecal medication is emphasized.
T h e following is a personal communication t o Dr. Morris J . Nicholson, dated
February 26, 106.4, f r o m Dr. W i n f r e y
W . Goldman, Jr., presently Director of
Medical Education, Tarrant County Hospital District, 1500 S o u t h M a i n Street,
Fort W o r t h , Texas.
-Editor
To my knowledge none of our five patients have developed any neurologic
complications subsequent to their discharge from the hospital.

We believe that the introduction of

trace amounts of phenols into the subarachnoid space produces an acute meningitis th at mimics an acute, bacterial
meningitis with the exception t h a t no
organisms can be found or cultured and
there is no depression of t h e cerebrospinal fluid sugar. We did not have t h e opportunity to follow a single patient in
this series reported without antibiotic
therapy because of the understandable
reluctance of t h e patients physician to
withhold such treatment. We, of course,
believe th at t h e i n j e c t i o n of t r a c e
amounts of phenol produces a n acute
meningitis picture which is seemingly
benign (in contrast to the reported serious sequelae thought to be due to detergents, and so forth) and t h a t antibiotics had no effect on the course.

REFERENCES
1. Biehl, J. P. and Hamburger, M.: Polymyxin B Therapy of Meningitis Following Procedures on Central Nervous System. Arch.
Int. Med., 93:367, 1954.
2. Nicholson, M. J. and Eversole, U. H.:
Neurological Complications of Spinal Anesthesia. J.A.M.A., 132:679, 1946.
3. Merritt. H. H. and Fremont-Smith. F.:
The Cerebrospinal Fluid, pp. 220-223. Philadelphia, 1937. W. B. Saunders Co.

4. Orkin, L. D.: Reported Mortality and

Morbidity Following Spinal Anesthesia. American Society Regional Anesthesia, Scientific
Session, March 3, 1936.
5. Kamsler, P. M.: Study of Changes in
Spinal Fluid Cell Count During Spinal Anesthesia. Anesth. & Analg., 30:103, 1951.
6. Kennedy, F., Somberg, H. M. and Goldberg, B. R.: Arachnoiditis and Paralysis Following Spinal Anesthesia. J.A.M.A., 129:664,
1945.
7. Yaskin, H. E. and Alpers, B. J.: Neuropsychiatric Complication Following Spinal Anesthesia, Ann. Int. Med., 23:184, 1945.
8. Thorsen, G.: Neurological Complications
After Spinal Anesthesia and Results From
2,493 Follow-up Cases. Acta chir. scandinav.
(supp. 121), 95:1, 1947.
9. Kennedy, F., Effron, A. S. and Perry, G.:
The Grave Spinal Cord Paralyses Caused by
Spinal Anesthesia. Surg., Gynec. & Obst., 91:
385, 1950.
10. Reynolds, K. E. and Wilson, G. J.:
Aseptic Meningitis Following Diagnostic Lumbar Puncture. J.A.M.A., 102:1460, 1934.
11. Bergner, R. P., Roseman, E., Johnson,
H. and Smith, R. W.: Severe Neurologic Complications Following Spinal Anesthesia. Anesthesiology, 12:717, 1951.
12. Winkleman, N. W.: Neurological Symptoms Following Accidental Intraspinal Detergent Injection. Neurology, 2:284, 1952.
13. Paddison, R. M. and Alpers, B. J.: Role
of Intrathecal Detergents in Pathogenesis of
Adhesive Arachnoiditis. Arch. Neurol. & Psychiat., 71:87, 1954.
14. Denson, J. S., Joseph, S. E., Koons, R.
A., Murry, W. E. and Disonnette, H. W.: E f fects of Detergents Intrathecally. Anesthesiology, 18:143, 1957.
15. Joseph, S. I. and Denson, J. S.: Spinal
Anesthesia, Arachnoiditis, a n d Paraplegia.
J.A.M.A., 168:1330, 1958.
16. Livingstone, H., Wellman, V., Clark, D.
and Lambros, V.: So Called Aseptic o r Chemical Meningitis. Surg., Gynec. & Obst., 77:
216, 1943.
17. Rendell, C. M.: Chemical Meningitis Due
to Syringes Stored in Lysol. Anaesthesia, 9:
281, 1954.
18. Hurst, E. W.: Adhesive Arachnoiditis
and Vascular Blockage Caused by Detergents
and Other Chemical Irritants: An Experimental
Study. J. Path. & Bact., 70:167, 1955.

If you w a n t your f a t h e r to take care of you, thats paternalism. If you w a n t your

mother t o take care of you, t h a t maternalism. If you w a n t Uncle Sam t o take c a r e
of you, thats Socialism. If you w a n t your comrades to take care of you, thats Communism. But if you want to take care of yourself, thats Americanism.
Rotumoor